Why I Hope Not to Die at 75

Posted on Friday, September 26th, 2014 at 8:00 am.

By James Sabin

I feel uniquely qualified to comment on Zeke Emanuel’s much-discussed article “Why I Hope to Die at 75.” I’m smack in the middle of the year he hopes will be his last. In addition, many years ago I wrote a book about health care organizational ethics with him (and Steven Pearson). I loved working with Zeke and admire the creative work he’s done on medical ethics and health policy.

Zeke says, correctly, that with limited exceptions, as we pass beyond 75 we typically lose physical and mental capacities, with the result, in his view, that “by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us, resulting in diminished productivity.” Although Zeke recognizes that we “accommodate [to] our physical and mental limitations” by diminishing our expectations and “restrict[ing] activities and projects, to ensure we can fulfill them,” at 57, he is horrified by the vision of diminution.

In Zeke’s view, to be remembered “framed not by our vivacity but by our frailty is the ultimate tragedy.” If a patient said this to me, I’d respond, “We can understand that losing vivacity and becoming frail is sad, but how can we understand why being remembered that way is ‘the ultimate tragedy’ for you?” Over the years, with patients who didn’t want to live beyond a particular age, we virtually always found highly personal fears underlying their picture of what the age meant.

We 75ers know from experience that Zeke has the facts right. I’ve experienced most of the changes he attributes to the age. But as is the case even for people who experience vastly more severe challenges than diminished aerobic capacity and declining productivity, most of us ferret out opportunities to contribute to the world and derive satisfaction. Many posts on Over 65 speak to this effort.

Zeke’s facts may be right, but what about the values he espouses? If Zeke were 17 his article would read as the exuberant outpourings of a brilliant adolescent. But he’s not 17 – he’s one of the leading bioethicists and policy experts in the world. As a result, rather than being understood for what he’s doing – presenting an unflattering view of himself in order to provoke thought in others, the Twitterati see him as telling others what values they should adopt. Even more foolishly, some claim that his highly idiosyncratic perspective, which I believe he will ultimately come to see as misguided, proves the truth of the “death panel” lie.

Many readers of Over 65 will agree with Zeke’s critique of American culture as too focused on the duration of life and too inattentive to the purposes of our lives. He calls this cultural type the “American Immortal.” But very few are likely to emulate his prediction that even if he is in excellent health at 75 he will decline all medical interventions except for relief of pain. No flu shots. No antibiotics for pneumonia.

If that view holds for the next 18 years, which I doubt will happen, I hope that when Zeke declines a flu shot or an antibiotic for a treatable infection his physician will be guided by “Four Models of the physician-patient relationship,” an article Zeke wrote in 1992 with his then-wife Linda. Here’s how they described the “deliberative model”:

“The aim of the physician-patient interaction [under the deliberative model] is to help the patient determine and choose the best health-related values that can be realized in the clinical situation . . . The physician’s objectives include suggesting why certain health-related values are more worthy and should be aspired to . . .” (emphasis added)

The values Zeke anticipates applying are not “the best health-related values” for a healthy 75 year old. It is not “worthy” to invite healthy life to end sooner than need be out of fear that we will be remembered as a frail elder, not as a vigorous youngster. That would be neurosis, not wisdom.

I mentioned above that I had the privilege of working on a project and writing a book with Zeke. I understood him to be a warm-hearted person and a gifted teacher who evinced respect and affection for a wide range of humanity quite independently of whether they were “creative” and “productive.” I believe the article he is being roundly attacked for is actually a gift. Zeke wants us to think seriously about what we value in life. By presenting views that many have found repugnant, and that I see as understandable but wrong, he’s achieving his purpose of provoking thought and discussion.

Zeke gives himself an out in the final paragraph of his long (5,000 words) article: “I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible.” (I trust by that he means “as long as possible” in a state in which he can appreciate life and respond to others in a meaningful way.) I’m prepared to bet that when Zeke turns 75 he will no longer regard youthful vigor and stunning productivity as the only values worth living for. If I’m alive, I’ll look forward to his contributions to Over 65 when he hits that birthday in 18 years!

Jim Sabin, M.D., 75, is an organizer of Over 65, a professor of population medicine and psychiatry at Harvard Medical School, and a Fellow of the Hastings Center.

9 Responses to “Why I Hope Not to Die at 75”

An elegant response to a provocative article. Several years ago I worked with Zeke Emanuel on projects related to research ethics and enjoyed and benefited from that collaboration. I have no doubt that he will be productive and active well into his 80s and beyond(if he gets over his fear of frailty). When I think of the people in my life who have died, I don’t remember them as old and sick at the very end of their lives (as most of them were), but as the vibrant persons they were at various younger ages. Memory is a mysterious thing and we can’t control how we will be remembered; we can only live so that the people who remember us will want to laugh and cry and recount the experiences we shared. On this Jewish New Year, I remember my parents, grandparents, and husband and and many others. I repeat alav ha-shalom (“of blessed memory”) to honor them. Meanwhile, I am getting a flu shot next week and thinking about what I want to write next.

Hi Carol
Thank you for the very thoughtful comment.
Intense fear of frailty is an especially male concern. I recall a case from years ago when a recently paraplegic young man asked his best friend to kill him. (The friend complied.)
My own experiences of memory are like yours. I recall my parents in their vulnerable states at the end of their lives but also as younger people and middle aged as well. The fear of being remembered as frail is, I believe, at heart a fear of humiliation. This is a prime concern for the relatively small number of folks in Oregon who ask for physician assistance in ending their lives.
Best
Jim

A subtext on male aversion to frailty: In 1930s urban slang, a “frail” (noun) was a woman — not an old woman and mostly likely a young one, a girlfriend or mistress. In Cab Calloway’s song, Minnie the Moocher was a “frail”–the “roughest and toughest,” which suggests that not all frails (noun) were frail (adjective. But the link to gender may persist.

Thank you so much, Jim, for bringing attention to Dr. Emanuel’s article and for your response. But where is the wisdom?
First, what is the significance of his pick of the age 75? As his own statistics show, someone born in 1960 (near his birth) would have expect a life expectancy of 69.7. So, at 75, he would outlive a male’s expectations, though I’m sure he benefits from his high SES, let alone possibly his genes.

Second, he gives himself a way out. “And I retain the right to change my mind . . .” From my experience as a psychiatrists, many people do change their mind about how they feel about living from 57 to 75.

Third, and I read his article three times and still couldn’t find the word, is his omission of the word “wisdom”. Wisdom seems to come from those long-developed neural networks that he seems to disparage. Perhaps he avoided discussing “wisdom” because it is less valued in the USA, but that is what elders around the world are usually valued for. I hope Dr. Emanuel is valued for his wisdom should he live beyond the age of 75.

All that leaves is searching for spiritual straws about what value his article merits, or what his real intent was. Let me go out on a real shaky limb here. Was it mystical, in that Gematria tradition of his people? Combine 57, his age, and 75, his desired death age, and you have 5775, the year of this Jewish New Year that just occurred. Add 18 years between them, as he does, and consider that 18 is the Jewish symbolic number of life. In the historical wisdom of his people, whether consciously or unconsciously, was he secretly saying something else?

Thank you for your remarkable speculations about possible mystical meanings in Zeke’s article. I have no sense of whether thoughts about numerology were in his mind, but I am sure that the way you responded is what he was hoping for – with thoughts of your own on the issues he is addressing.

Jim–What’s in a date? Summer ended and fall began on September 22. We will have some warm days, and maybe even “Indian Summer.” But summer is over. We can’t reposition the earth and sun to bring summer back. Let’s accept and enjoy fall, and winter too. So too with turning 75. I agree with Dr. Emanuel that relatively speaking, we spend too much on the medical care of people near the end of life and not enough on people at the beginning of life. And I’m a geriatrician. As an attendee at a recent medical conference said, “The epidemic of childhood obesity should be seen as nation-wide child abuse.” p.s. To continue the metaphor of the seasons, there is an artificial way to bring eternal summer, which is in progress now, with human-induced climate change. Who would want to live in such a world, brought about by the toxic side effects of our quest for progress. Or, we could have eternal winter following a nuclear war.–Eric

Hi Eric
Your evocation of the seasons is very poetic and reminds me of some of Shakespeare’s sonnets about aging. Your comments brought to mind as well a surfing movie from almost 50 years ago – “The Endless Summer.” Like you, I also agree with Zeke Emanuel that over 65ers like myself are at risk for overtreatment. He doesn’t focus on costs in his (misguided) article, but in addition to the harms to individual patients from overtreatment, our national search for an “endless summer” entails costs that rob other areas that should be getting more attention.
Best
Jim

Really! How will living “as long as possible” be interpreted under “managed health care” and “managed death” CMS/Advantage Insurance reimbursement protocols that already, and since 2006, at least, have been targeting the frail elderly/disabled on Medicare/Medicaid for savings in end-of-life care? The under-the-radar public policy of keeping the elderly/disabled/frail patients out of expensive ICU and CCU Care in our public hospitals is hastening the death of some of the elderly without their knowledge or informed consent.

If living “as long as possible” remains unclear in the law, does this mean that Medicare/Medicaid patients will only live as long as CMS/Advantage Insurance reimburses their hospital care?

Will Medicare/Medicaid patients have to be informed that their Medicare Part A insurance or Part C Advantage Insurance will not reimburse their treatment in the hospital so that they can negotiate a private payment for life-extending or life-saving treatment that provides a chance of them living as “long as possible” and as long as they want to live?